Life Care Planning for Acquired Brain Injury – Anatomy of the Brain (I)
Life Care Planning for Acquired Brain Injury – Case study and Conclusion (III)
Brain injuries can be classified by a number of methods (Marshall et al., 1992; Teasdale et al., 1992). ABIs are generally classified as traumatic, anoxic/hypoxic-ischemic, vascular, or other.
Anoxic or hypoxic-ischemic brain injuries occur when areas of the brain do not receive enough oxygen. This is frequently the cause of secondary injury after a traumatic injury, but may also occur independently of trauma. The most frequent cause of hypoxic-ischemic brain injury is secondary to myocardial infarction or heart failure. During resuscitative efforts for a heart attack, the brain may be deprived of oxygen for several minutes. Vascular brain injuries, commonly called strokes, most commonly occur as a result of thromboembolic phenomena. However, other types of vascular brain injuries include aneurysms, arteriovenous malformation, and spontaneous intracranial hemorrhages. Finally, injury to the brain may occur as a result of viral or bacterial infections, metabolic derangements, or tumors.
Traumatic brain injuries, the broadest category of ABI, may be further subdivided a number of ways. One of the most basic methods of subcategorization is to divide them between open or closed. Open injuries are those injuries in which there is disruption of the scalp and skull, creating the possibility that the brain may be contaminated by material from the outside environment. Penetrating brain injuries are a type of open injury, in which a foreign body (such as a bullet) passes through the skull and outer coverings of the brain into the brain tissue itself. Closed head injuries are those in which the skull remains intact and the brain is not exposed to the outside environment, although significant injury may occur from the impact of the brain against the inner part of the skull, or from shearing of axons secondary to rotational forces.
Medical professionals caring for survivors of brain injury will also classify the injuries based on severity. The most common, widely utilized method of classification is the Glasgow Coma Scale, a method that classifies injuries based on clinical presentation (see Table 13.1). A medical professional will rate the patient’s response in three separate areas: eye opening, motor response, and verbal response. The scale gives scores for each of the areas, which are summed to give a total score that can be used to rank the severity of the injury. Individuals who score 3 to 8 are said to have a severe injury, from 9 to 12 a moderate injury, and from 13 to 15 a mild injury. This information may be useful to predict the outcome and likelihood of long-term impairments (Clifton et al., 1993; Zafonte et al., 1996; Teasdale et al., 1998).
Other methods of rating injury severity are available but not as widely utilized. One alternative method of injury classification uses duration of posttraumatic amnesia as the best method of predicting outcomes following TBI (Zafonte et al., 1997). Other methods of classification have tried to use radiographic findings, such as location and size of lesions on computed tomography (CT) or magnetic resonance imaging (MRI) (Teasdale et al., 1992). However, the correlation between radiographic findings and clinical presentation is often poor. Newer MRI techniques are now available in some areas, which have greater sensitivity to injured brain tissue and greater clinical correlation with functional status (Gerber, Weintraub, Cusick, Ricci, & Whiteneck, 2004).
Another broad categorization of brain injury is to divide between diffuse and focal brain injuries. Diffuse injuries are generally due to shearing injury of the axons and generally occur across a broad area of the brain. Focal injuries occur with trauma to one specific region of the brain. These two types of injury may occur concomitantly. In general, focal injuries result in shorter periods of unconsciousness than diffuse injuries. Individuals with diffuse injury, sometimes referred to as diffuse axonal injury (DAI), may have prolonged periods of unconsciousness from several days to weeks. In general, individuals with DAI have a prolonged recovery period compared to those with focal injuries (Bontke & Boake, 1991; Berker, 1996).
When a patient presents to the emergency room following TBI, the initial activities focus on life preservation. Often, concomitant injuries preclude addressing the brain injuries until later in the course of treatment. However, for those patients with severe injuries, the initial protocols involve rating the patient’s level of arousal using the Glasgow Coma Scale, and some form of neuroradiographic imaging. At this time, CT scan remains the preferred type of image, due to the relatively faster speed with which images can be obtained and the fact that the types of injury that require emergency surgical intervention show much more readily on CT than MRI. However, there is some discussion about whether newer MRI techniques are more sensitive to intracranial injury (Levin, 1992; Marshall et al., 1992; Rappaport et al., 1992; Piek, 1995; Horn & Zasler, 1996; Gerber, Weintraub, Cusick, Ricci, & Whiteneck, 2004).
Incomprehensible verbal utterances(Sum of score from each of three areas)Note: A score with a T (e.g., 8T) means the patient was intubated for airway purposes and may be unable to fully respond.
Once the patient is stabilized, a more detailed assessment of the injury will occur, and further treatment may be recommended. For severe injuries, assessment by a neurosurgeon will usually occur. If there is evidence of specific, severe types of bleeding or increased pressure inside the head, surgery will be performed to evacuate the blood or alleviate the pressure. Sometimes an intracranial pressure monitor will be placed to accurately measure the pressure inside the brain.
Patients frequently require assistance with basic life functions. They may be placed on a mechanical ventilator to help them breathe. For prolonged management, sometimes a tracheotomy is performed to facilitate prolonged ventilator support. Additionally, for patients that are unconscious for prolonged periods of time, a feeding tube may be surgically introduced. Many patients with severe injury will also sustain injuries to other parts of their body as well. Surgical attention is often necessary during the early hospitalization to address fractures, damaged internal organs, internal bleeding, and other medical concerns.
While patients are still in the hospital, physical and occupational therapy referrals should occur to maintain joint range of motion and strength and to begin working on activities of self-care. The more severely injured patients should be referred to a rehabilitation facility following their acute hospitalization to begin the work of trying to be restored to their highest level of functioning. An assessment by a physiatrist, a medical doctor with training in physical medicine and rehabilitation (PM&R), is important during this phase to facilitate the coordination of services and medical treatment to promote the best outcome following TBI (Rosenthal, 1990; Almli & Finger, 1992; Bontke et al., 1993; Berker, 1996; Semlyen et al., 1998).
Patients will often require further medical and rehabilitation care after medical issues are stabilized (Cope, 1995). Several different levels of rehabilitation care are possible, and the best appropriate level of care depends on the acuity of the concomitant medical issues as well as the level of functioning of the patient (Evans, 1992; Mazmanian et al., 1993; Hall & Cope, 1995; Schmidt, 1997). Patients who cannot participate or tolerate several hours of therapy each day are most appropriately sent to a subacute rehabilitation program until they can tolerate a more aggressive therapy program. The most common level of rehabilitation care is acute inpatient rehabilitation, where patients receive 3 or more hours of therapy a day from several different therapy disciplines (i.e., physical therapy, occupational therapy, speech therapy), as well as ongoing medical attention (Malec & Basford, 1996). Once patients are medically stable and safe to be managed at home, therapy efforts transition to an outpatient setting. Rehabilitation day programs are therapy programs designed for individuals who still need therapy from several different disciplines in a team format, but no longer need as close medical attention as individuals in the acute inpatient setting. Some individuals will not need the interdisciplinary model of therapy, but only require therapy from one or two disciplines; then single-service outpatient therapy is indicated.
An adept life care planner who works with survivors of brain injury must be aware of the potential medical complications that arise following brain injury and their impact on recovery, long-term function, and reintegration in the community. As the brain is the control center for all neurological processes in the body, injury to the brain can result in complications to almost every organ system. It is beyond the scope of this post to discuss all complications, although there are several common complications that we will describe (Kraus, 1984, 1991; Corrigan & Mysiw, 1988; Bigler, 1989; Bloomfield, 1989; Russell-Jones & Shorvon, 1989; Uomoto & Brockway, 1992; Bontke et al., 1993; Jore et al., 1993; Katz & Alexander, 1994; Kaufman et al., 1994; Piek, 1995; Cifu et al., 1996a).
Injury to the cranial nerves frequently occurs following TBI. As a result, patients may have difficulty with basic sensory functions, such as vision, hearing, smell, and taste. Facial paresis is frequently seen, with resultant difficulty in oromotor functions, as in speaking, resultant dizziness, and balance disorders. This by itself may lead to problems with standing, walking, and transfers. It is very common for the olfactory nerve, the cranial nerve that controls sense of smell, to be damaged due to its structure, sometimes resulting in problems with eating and appetite. Fractures of the temporal bone, a part of the skull, can result in disruption of the cranial nerve associated with hearing, resulting in hearing impairment.
Many patients will have significant difficulty with vision problems following brain injury. Problems may range from inability to see objects in certain parts of the field of vision (sometimes referred to as a field cut) to blurry or double vision. This may be due to injury to the visual pathways within the brain, to injury to the nerves that control eye movements, or to injury to the eye itself. An evaluation by a neuro-ophthalmologist, a physician with training in neurological disorders that affect vision, is sometimes very helpful.
Endocrinology is the study of hormones and their function. Many hormones are regulated or secreted by the pituitary gland, a structure at the base of the brain. The pituitary can frequently be damaged during injury to the brain due to its location and structure. Common endocrine disorders following brain injury include syndrome of inappropriate diuretic hormone (SIADH), growth hormone deficiency, and irregularities of gonadal steroid production. Endocrinopathies are much more evident in women, because menstrual irregularities, as a result of altered pituitary- gonadal axis functioning, may persist for a year or longer after brain injury. This may also be a source of problems with infertility following injury.
Patients with severe TBI frequently have respiratory failure as sequelae of the initial trauma. As a result, patients often require mechanical ventilation with a breathing machine (ventilator). Sometimes physicians must perform a tracheotomy, or a surgically created hole, to allow the patient to breathe and to help prevent complications from prolonged ventilator management. Patients who are immobile for prolonged periods of time are at a higher risk for developing pneumonia. A pulmonary embolus, or a blood clot that lodges in the blood vessels of the lungs, is also a potential complication of prolonged immobility.
Direct effects of brain injury on the cardiovascular system are infrequent. However, immobility may lead to secondary complications over time. The most common is the formation of deep vein thromboses (DVTs) or blood clots in the veins. These clots can be potentially life threatening, as they can break free and lodge in the lung vessels causing a pulmonary embolus, as noted previously. DVTs may also result in postphlebitic syndrome, or a painful condition of inflammation of the veins. Another complication that may lead to cardiovascular injury is called central storming, in which abnormally high levels of stimulant hormones are released into the bloodstream, resulting in fevers, high heart rates, and high blood pressure. This phenomenon can result in heart injury to people who are susceptible.
Typical neurological problems include weakness, sensory deficits, and the previously mentioned cranial nerve problems. Individuals who have had a brain injury are at increased risk for developing seizures. The presence of a penetrating brain injury, skull fracture, or significant amounts of subarachnoid blood increases the risk for seizures. The upper motor neuron syndrome is possibly the most frequently seen neurological complication after all forms of brain injury, with its constellation of symptoms of weakness, spasticity, and increased reflexes. Spasticity is a velocity-dependent increase in motor tone that is seen frequently following injury to motor nerves in the central nervous system. This is such a profound problem after brain injury that it will be discussed in detail later in the post. Additionally, cognitive and behavioral problems are frequent neurological complications and will also be discussed in more detail later.
Patients frequently exhibit dysphagia, or impairment in the ability to swallow, as a result of weakness of the pharyngeal muscles. Often, patients require the placement of a feeding tube to prevent aspiration of food and to allow for feeding while the pharyngeal muscles remain weak. Additional gastrointestinal problems may include incontinence secondary to neurological impairment of the muscles controlling bowel function or alternatively from cognitive impairment. Constipation is frequently seen due to the same alteration in neurological functioning of the bladder, or often due to medications.
Neurological control of the bladder may be impaired, resulting in incontinence. However, most cases of incontinence following brain injury are a result of disinhibition instead of true neurological impairment. Patients with neurological impairment of bladder function may retain urine, which can lead to other problems, including frequent infections of the urinary tract, infection of the kidneys, and renal and bladder stones. Sexual dysfunction may also be an issue, although, again, these problems are predominately behavioral as opposed to physiological impairment of sexual functioning. Frequently, sexual inhibition may occur as a result of altered body image due to impairments such as weakness, spasticity, or changes in physical appearance due to the injury, although more frequently, patients become sexually disinhibited due to injury to the areas of the brain responsible for control of impulsive behavior (Kreuter et al., 1998). Sexual functioning is an area that is
frequently overlooked by medical professionals. In women, infertility may occur secondary to the endocrine changes mentioned earlier.
Musculoskeletal complications are very common following brain injury. Injury to the motor nerves in the brain may result in the upper motor neuron syndrome, which consists of the constellation of symptoms of spasticity, weakness, and hyperreflexia. Areas of weakness can vary depending on where the injury is located in the brain. Due to the brain’s structural organization, injury on one side of the brain results in weakness on the opposite side of the body. Additionally, the weak side is frequently associated with spasticity. If unchecked, spasticity and immobility may ultimately result in contractures, which is tightening of the soft tissues and shortening of tendons around a joint resulting in a reduction in the patient’s mobility. As a result of associated trauma, patients with brain injuries also frequently have associated fractures, peripheral nerve injuries, or soft tissue injury that can also make rehabilitation difficult. An interesting musculoskeletal problem that sometimes occurs following TBI is heterotopic ossification, a condition in which bone is formed inappropriately in soft tissue areas. This problem, if left untreated, can result in ankylosis, or fusion of a joint, such that moving it is impossible. Extremity pain may also be a problem, due to inherent injury to the extremity or from neurological damage to the sensory pathways.
Injury to the brain can result in any number of changes in mental function, including changes in personality. The specific changes, of course, depend on the specific structures damaged. Very commonly, brain-injured patients experience problems with memory, attention, and arousal, as well as difficulties with language and communication (Seel et al., 1997). Even patients who experience a relatively good recovery will often have subtle cognitive deficits that make returning to work or living independently difficult. A list of potential cognitive problems after TBI can be found in Table 13.2 (Groswasser & Stern, 1998).
Recovery from brain injury is a highly variable process. Severely injured patients recover in general along a set of stages, classified as the Rancho Los Amigos Scale of Cognitive Functioning (see Table 13.3). Patients do not always progress through each stage in a stepwise fashion; some patients may skip one or more stages. This scale has its greatest usefulness in communicating with other team members about the condition of the patient, although at times it is helpful for family members, particularly when patients are in an agitated state. Some families find it somewhat comforting to know that the agitated state is part of a normal recovery process following TBI.
Potential Cognitive Problems after TBI Rancho Los Amigos Scale of Cognitive Functioning—Revised Unresponsive: total assistanceComplete absence of change in behavior when presented any stimulus.Generalized response: total assistanceGeneralized reflex response to painful stimuli; may increase or decrease activity in response to repeated auditory stimuli; responds to external stimuli with generalized physiological changes; gross body movement; responses may be significantly delayed.Localized response: total assistanceWithdraws from painful stimuli; may turn away or toward auditory stimuli; may track object that passes across visual field or blink to visual threat. Responds inconsistently to simple commands; may respond to some people and not others.Agitated/aggressive:maximalassistanceAlert, in heightened state of activity. Purposeful attempts to remove tubes and restraints; may exhibit aggressive or flight behavior. Emotionally labile, unable to cooperate with rehabilitation efforts. Verbalizations are incoherent and inappropriate to activity or environment.Confused-inappropriate:maximalassistanceAlert, not agitated, disoriented. Frequent brief periods of nonpurposeful sustained attention. Severely impaired memory. Unable to learn new informtion. May demonstrate inappropriate use of external object. Able to converse on a social and automatic level for brief periods of time.Confused-appropriate:moderateassistanceInconsistently oriented to person, time, and place. Able to attend to highly familiar tasks in nondistracting environment for prolonged periods of time. Able to use memory aid with assistance. Begins to show carryover for relearned familiar tasks. Verbal conversations are appropriate in familiar and structured situations.Automatic-appropriate:minimalassistanceConsistently oriented to person and place within highly familiar environments. Able to attend to highly familiar tasks in nondistracting environment for at least 30 minutes with minimal assistance to complete tasks. Minimal supervision for new learning. Shallow recall of personal activities. Superficial awareness of his/her condition but unaware of specific impairments and the limits they place on the ability to safely, accurately, and completely carry out household, work, and leisure ADLs.Purposeful-appropriate:standbyassistanceConsistently oriented to person, place, and time. Able to attend to and complete familiar tasks for 1 hour in distracting environment. Able to recall and integrate past and recent events. May be able to use memory aids with supervision; aware of impairments on a superficial level but needs assistance to undertake appropriate corrective action. May demonstrate low frustration tolerance, irritability, and become argumentative.May be able to recognize socially inappropriate behavior and take corrective action with assistance.
Purposeful- appropriate: standby assistance on requestAble to independently shift back and forth between tasks and complete them accurately for at least 2 consecutive hours. Uses memory devices appropriately when reminded; may be able to initiate and carry out steps in familiar household, work, and leisure tasks with assistance when requested. Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action with supervision when requested. May continue to have low frustration tolerance, irritability, and depression, but able to monitor social interaction more appropriately with only standby assistance. May be able to think about consequences of actions or decisions when requested.Purposeful-appropriate:modifiedindependentAble to handle multiple tasks simultaneously in all environments but may require periodic breaks. Able to independently procure, create, and maintain own assistive memory devices. Independently initiates and carries out self-care, household, community, work, and leisure tasks, but may require more time or compensatory strategies to complete them. Able to independently think about the consequences of decisions or actions but may require more than the usual amount of time or compensatory strategies to select the appropriate decision or action. Social interactions are fairly consistently appropriate.Most sources indicate that full neurological recovery of the brain following a severe injury takes approximately 1 year. Although this is a good estimate for most patients, there are certainly exceptions, and some patients have demonstrated significant recovery even after 1 year. Researchers are learning more about the process of neuroplasticity and factors affecting better outcomes (Ginsberg et al., 1997; Pike & Hamm, 1997).
Impairments following brain injury may include almost any complication imaginable. However, there are certain impairments that occur with such regularity after TBI that they warrant special mention. These impairments are the main issues that cause long-term problems after brain injury. Any life care plan for a patient who is traumatically severely injured should be sure to address these particular issues.
¦ Weakness: Injury to the motor cortex or motor pathways may lead to weakness. Severe enough injury will result in paralysis. Weakness is usually the biggest factor affecting a person’s ability to perform activities of self-care, such as dressing, grooming, and feeding. It
may also impair an individual’s ability to walk and move about and, in extreme cases, may lead to the necessity of assistance with transfers.
¦ Spasticity: Spasticity, defined as “velocity-dependent increase in motor tone,” as mentioned earlier in the post, often remains a huge obstacle to independence after a brain injury. Spasticitiy is manifested clinically as an involuntary “tightening” of the muscles, resulting in difficulty moving a joint through normal range of motion. Spasticity is often associated with weakness and further complicates the patient’s ability to move and perform activities of self-care. Furthermore, severe spasticity places the patient at risk for a number of other complications, such as contractures and skin breakdown. Much of the medical treatment following TBI centers around the prevention and treatment of spasticity. A number of medical interventions in the treatment of spasticity have become available in recent years. Aside from oral medications and therapeutic interventions such as splinting, casting, bracing, and range-of-motion exercises, patients are frequently treated with a variety of injections for spasticity. These may include nerve blocks using ethanol or phenol or, more commonly now, botulinum toxin injections. A newer treatment device, the intrathecal pump, may be surgically implanted to provide a higher concentration of medicine for spasticity directly at the level of the spinal cord, where it is most effective. The advantage to this technique is that it allows greater control over the administration of medicine, while avoiding many of the side effects associated with oral administration of medication. This treatment is not for everyone, however, and should be discussed with the patient’s doctor. Finally, various surgical techniques may be used, usually as last-resort efforts, for treatment of spasticity. These include various tendon-lengthening procedures, rhizotomy, or cordotomy.
¦ Behavioral problems: Although other issues may be more of a focus of medical treatment, it is often behavioral issues that prevent successful community reintegration and return to gainful employment. Patients may have low frustration tolerance, impaired judgment, and, in many cases, emotional lability or frank aggression that hinder successful rehabilitation outcomes. Behavioral problems are usually addressed on a number of levels, including psychological counseling, behavior modification plans, medications, and, in worst cases, inpatient neurobehavioral treatment programs.
¦ Cognitive: Several studies have examined the frequency of patients’ complaints following TBI. The most common complaint in all studies is problems with memory. Areas of the brain associated with memory formation are particularly susceptible to injury following trauma, due to their proximity to bony protuberances inside the skull. Additionally, these structures are particularly susceptible to anoxic injury as well, which can occur secondarily following trauma. Deficits in attention, motivation, and sensory input can also secondarily result in memory problems.
¦ Aging: As noted below in the vocational category, aging with a brain injury can result in a faster than average decline physically as well as cognitively. Reduced physical skills and judgment can also result in additional injury as time passes. Indeed, once a person has experienced a brain injury, he or she is much more likely to have a second injury than people without a brain injury. Also, for some mild to moderately brain-injured clients, social isolation and awareness of deficits eventually erode the hope and optimism that occur while progress is being made, and behavior and emotional problems may rise several years after the original insult. These problems are not as much related to aging as to the passage of time and the slow realization that they will never achieve their preinjury levels and may be unable to enjoy normal social and love relationships (Trudel & Purdum, 1998).
Successful return to the community remains a significant challenge given all of the potential barriers a patient may face due to the impairments sustained as a result of the injury (Berens, 2008; Smith- Knapp et al., 1996; Wall et al., 1998). With changes in personality, and behavioral problems, interpersonal relationships often become difficult. Many patients require ongoing supervision for safety reasons, which interferes with social activities. Driving a motor vehicle is a significant concern, and a formal driving evaluation should be performed by a therapist trained to look for the specific problems that may interfere with safe driving.
An additional issue frequently seen is return to recreational activities. A high percentage of brain injury patients engaged in high-risk activities prior to their injury (Chesnut et al., 1993). In fact, it is often engagement in high-risk activities that led to the brain injury in the first place. It is extremely important that individuals protect themselves against a second injury, particularly while the brain is healing. The second impact syndrome, in which a person healing from one injury is exposed to a second injury, may result in exponentially worse or even fatal outcomes, even with a relatively minor second injury. It is therefore extremely important that the patient be restricted from engaging in activities that may place him or her at risk for another injury. A therapeutic recreation specialist may be helpful in identifying and developing appropriate leisure interests after brain injury as well as helping develop techniques to pursue those interests when physical and cognitive impairments make them difficult. In addition, substance abuse may adversely affect recovery and ultimate outcome, further complicating the vocational and life care planning needs (Corrigan, 1995).
Return to gainful employment after brain injury remains a significant challenge (Dikmen et al., 1994; Goodall et al., 1994; Ip et al., 1995; Wehman et al., 1988, 1993; Stapleton et al., 1989; Cifu et al., 1997; Zasler, 1997). Most studies indicate that following a brain injury, approximately one-quarter to one-third of individuals return to work within a 1- to 2-year period following the injury (Traumatic Brain Injury National Data and Statistical Center, 2004). Even with milder brain injuries, work-related issues often become the major problem due to significant problems with interpersonal relationships and behavioral changes (Baker, 1990; Chwalisz, 1992; DePompei
& Williams, 1994). Most TBIs occur in individuals between the ages of 16 and 30, a time in most people’s lives when education is being completed and career goals established. For those who have completed their education, the cognitive problems often prohibit the use of previously gained knowledge. Additionally, memory problems may make further education or training impossible, in the worst cases.
It is strongly recommended that individuals undergo a neuropsychological evaluation to determine their capacity for education and work (Weed, 1996, 1998; Macciochi et al., 1998). A proper, thorough neuropsychological evaluation will give information about how the patient learns and processes information, and will help the vocational rehabilitation counselor in establishing appropriate return-to-work goals. Many clients, in fact, are unable to return to competitive employment due to their impairments, or need significant support and assistance to do so. Many patients have no difficulty obtaining employment, but have a great deal of trouble maintaining employment.
In addition to the standard evaluation report, add the following as appropriate:Please describe, in layman terms, the injury to the brain.Please describe the effects of the accident on the client’s ability to function.Please provide an opinion to the following topics: Intelligence level? (include pre- vs. postincident if able)Personality style with regard to the workplace and home?Stamina level?Functional limitations and assets?Ability for education/training?Vocational implications—style of learning?Level of insight into present functioning?Ability to compensate for deficits?Ability to initiate action?j. Memory impairments? (short-term, long-term, auditory, visual, etc.) k. Ability to identify and correct errors? l. Recommendations for compensation strategies? m. Need for companion or attendant care?
What is the proposed treatment plan? Counseling? (individual and family)Cognitive therapy?Reevaluations?Referral to others? (e.g., physicians)Other?How much and how long? (include cost per session or hour and reevaluations)Source: Roger O. Weed, with acknowledgment to Robert Frasier for some content.Research regarding employment suggests that the most difficult to place long term are people with mental illness and brain injury.
In order to adequately assess the vocational and life planning needs of a person with a brain injury, it is recommended that, as clinical judgment dictates, other allied health professionals be considered. The occupational therapist may be an appropriate referral for an assessment for seating and positioning, adaptive aids, and other vocationally related issues. For some clients, activities of daily living training, including household safety, would be included. The speech and language pathologist will be instrumental in determining augmentative communications and assistive technology for clients with more severe injuries, as well as in providing an assessment of receptive and expressive speech and language. They also often offer cognitive remediation strategies. A physical therapist is often the most appropriate referral to determine the client’s true physical capabilities by compiling a functional capacity assessment (or physical capacity assessment) that is more detailed than most physicians can report. For the young adult or pediatric case, an educational consultant can be very important to maximize the client’s educational potential. Under the Individuals with Disabilities Education Act (IDEA), the public school system is responsible for providing specialized services to children with disabilities. However, many of these clients are unserved for a variety of reasons. One reason is that the client has not been adequately assessed in order to identify deficits that would meet the criteria for specialized education. Another reason is that the client may meet the definition, but the school’s funding is inadequate and the school will fail to provide appropriate support. Educational consultants who are familiar with the rules often can negotiate the appropriate education protocol.
Several methods ofvocational assistance have been developed, including sheltered workshops and supported employment. The supported employment model involves a job coach who spends time with the patient at the worksite and assists with training the patient for the job, accommodations of the workspace if necessary, and helping with problems that may occur if needed. Much of the support involves educating the employer about the nature of brain injury (McMahon & Shaw, 1991; Wehman et al., 1993).
In addition, the effects of aging with a brain injury may affect work life expectancy (Weed, 1998). Data reveal that many clients with a brain injury cognitively or physically deteriorate at a faster rate and appear years older than their chronological age; it is not uncommon for clients to depart from work (i.e., retire early) at an age younger than that of most able-bodied workers. Reduced physical skills from the initial injury mean the person has less of a reserve than the average person, so as he or she ages, he or she may reach the threshold of dependence at an earlier age. There also may be an increased risk of Alzheimer’s disease at an earlier age, leading to loss of independence earlier than with the average person (Chandra et al., 1989; Gedye et al., 1989; Rosenthal, 1990; Cifu et al., 1996b; Thompson et al., 1997). For example, it may be appropriate to phase out work and phase in a day program or volunteer activities by the time the client is in his or her fifties. The decline in work life can also be a result of moving from full-time to part-time work as well as earlier retirement.
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